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Case Reports
. 2024 Oct 31:15:1474663.
doi: 10.3389/fimmu.2024.1474663. eCollection 2024.

Case report: Partial regression of metastatic squamous cell carcinoma with altered azathioprine dosage after long-term use in renal transplant patient

Tegan Ormston  1 , Jessica Da Gama Duarte  2 , Luke T Quigley  2 , Louise Jackett  3 , John Whitlam  4   5   6 , Andreas Behren  2   7 , David E Gyorki  8   9
Affiliations
Case Reports

Case report: Partial regression of metastatic squamous cell carcinoma with altered azathioprine dosage after long-term use in renal transplant patient

Tegan Ormston et al. Front Immunol. .

Abstract

Introduction: We report the partial regression of metastatic squamous cell carcinoma (SCC) after reduction of long-term azathioprine therapy while awaiting surgery. The patient was a 69-year-old man with a history of kidney transplantation. Moderately differentiated SCC arising in the anterior neck was initially diagnosed, followed later by poorly differentiated SCC metastases to cervical lymph nodes. Lymph node clearance was performed 28 days after a reduction in azathioprine dosage. The palpable lymph node lesion had noticeably decreased in size at the time of surgery, and subsequent histology only detected 7mm and 0.2mm deposits of poorly differentiated SCC in 2 of 5 level I nodes, and a further 10 reactive nodes from levels II and III. One positive level I and another benign level II/III node, demonstrated necrosis, histiocytic infiltration and fibrosis, interpreted as features of regression. Hence, we investigated the role of immune cells in the partial regression of metastatic SCC after reduction of long-term azathioprine therapy while awaiting surgery.

Methods: Multispectral immunohistochemistry using custom markers was performed on regions of interest of excised cervical lymph nodes, encompassing the entire SCC deposit and the surrounding adjacent stroma to quantify to number and types of immune cells present.

Results: Multispectral immunohistochemistry revealed the heavy infiltration of activated T cells in the tumour, as well as PD-L1+ antigen-presenting cells in the surrounding adjacent stroma, suggesting an immunologically mediated partial regression.

Discussion: We hypothesize that this reaction was triggered by azathioprine dose reduction. Dose modification of long-term immunosuppressive medications in patients with a transplantation history who later develop SCCs warrants further investigation.

Keywords: case report; cutaneous squamous cell carcinoma; immunosuppression; kidney transplant; metastatic squamous cell carcinoma.

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Conflict of interest statement

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. The author(s) declared that they were an editorial board member of Frontiers, at the time of submission. This had no impact on the peer review process and the final decision.

Figures

Figure 1
Figure 1
Immune-fluorescence images of a submandibular lymph node containing a 7mm deposit of poorly differentiated SCC. This includes (A) whole slide scans (WSS) and (B) Representative regions of interest (ROI) showing merge and single staining for panel 1: CD3 (red), CD4 (yellow), CD8 (green), granzyme B (magenta), CD103 (cyan), and panCK (orange) antibodies with DAPI (blue) counterstain (upper immune-fluorescence panel); and panel 2: CD3 (red), PD-1 (green), PD-L1 (magenta), CD68 (cyan), MHC class II (yellow) and panCK (orange) antibodies with DAPI (blue) counterstain (lower immune-fluorescence panel). All images were taken at 20x magnification, and scale bars indicate 100μm.
Figure 2
Figure 2
Clinical timeline detailing full patient history, and immunosuppressive medication.
See this image and copyright information in PMC

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